Client satisfaction to methadone maintenance treatment program in Myanmar

The Global Health Observatory data from the World Health Organization (WHO) had highlighted that in 2014, 45% of the 147 responding countries had methadone therapy chiefly for OUD detoxification purposes [28]. The World Drug Report 2020 from the United Nations Office on Drugs and Crime (UNODC) estimated that 57.8 million people had used opioids in 2018, and 80% have lost 42 million years of “healthy life” to OUD [26]. Drug dependence has been described as a multi-factorial health disorder with a high possibility for relapse even after seeking treatment. Thus, it is imperative that people who use opioids be enrolled in opioid substitution treatment programs to cut the vicious cycle of addiction and halt the spread of infectious diseases such as HIV.

Myanmar, a country that accounted for 7% of the world’s opium production [26], continued to face significant problems with opioid misuse. To curb this menace, punitive laws have been enforced, where people who use drugs can be detained and jailed for misusing illicit substances. Given the opiate misuse threat and its link with HIV spread, the Methadone Maintenance Treatment (MMT) program was first introduced in Myanmar in 2006 as a harm reduction intervention. Owing to its success, the MMT program has been expanded throughout Myanmar in line with the recommendations from the National Drug Control Policy [3]. The DDTRU first started the MMT program in Myanmar with 260 clients before it was gradually upscaled [6]. As of 2020, 26,016 people who inject drugs (PWIDs) (i.e. 28% of 93,000 estimated PWIDs in Myanmar) were taking methadone [21]. Like any other program, this harm reduction intervention could have faced challenges, obstacles and limitations in its service delivery. It would be beneficial to monitor such impediments by assessing client satisfaction towards the MMT program.

It has been pharmacologically shown that the MMT program is effective as it is associated with decreased opioid use [29]. Improvement in the quality of life (QoL) has been reported for clients enrolled in the MMT program for the short term [8], as well as long-term duration [4]. Furthermore, the MMT program clients were less likely to resort to illicit opioid use [30] and were reported to be satisfied with ancillary treatment services often provided in the MMT program [9]. Given the rapid expansion of the MMT program, several validated tools have been developed to assess clients’ treatment satisfaction with the MMT program. Commonly used tools include the Client Satisfaction Questionnaire (CSQ-8) [11], the Service Satisfaction Scale (SSS-30) [19] and the Verona Service Satisfaction Scale (VSSS-32) [18]. Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS) is a tool that could be modified and used to assess satisfaction towards the methadone services.

A recent situational analysis indicated that MMT programs are bound to have several limitations or barriers. They are inconvenient operational hours, long travel distance to MMT sites, lengthy registration process, coping with the continuous drug use issue among clients, long induction period, and a lack of confidentiality [14]. In view of ongoing MMT program expansion in Myanmar, it has become crucial to explore clients’ satisfaction towards the MMT program and its ancillary services so that timely remedial measures could be taken to enhance the user-friendliness of the program. As such, this study aims to evaluate the satisfaction of the clients enrolled in Methadone Maintenance Treatment Program in Myanmar with the following objectives:

1) to explore clients’ overall satisfaction towards the program in general;

2) to assess clients’ satisfaction towards a) professional skills of the clinic staff; b) basic drug intervention (Methadone administration); c) specific intervention such as individual rehabilitation and psychotherapy,

3) to find out if any of clients’ characteristics are associated with their satisfactory response.

Among three categories of methadone service that captured treatment satisfaction, the rating for professional skill items (skills of doctor, nurse, counsellor and workers) scored the highest (3.89 out of 5), while items in specific intervention category scored the lowest. A Vietnamese study [22] also reported high satisfaction in professional skill items. It was reported that MMT programs that offered ancillary services as specific intervention improved MMT satisfaction ([12, 22]. It was reported that limitations or barriers such as dosing spaces, waiting areas and staff shortage could affect treatment satisfaction [2]. Thus the specific intervention component in MMT programs could be enhanced by providing ancillary services such as counselling, medical services (Individual rehabilitation), psycho-social services (psychotherapy and group therapy), and psychiatric care. Thus, the specific intervention component in MMT programs could be enhanced by providing ancillary services such as counselling, medical services (Individual rehabilitation), psycho-social services (psychotherapy and group therapy), and psychiatric care. As the specific intervention focuses on individual and group counselling, family support, and the centre supports at home, the methadone intervention can be more effective if integrated with individual and/or group counselling, employment or family services [1]. Moving in this direction could improve clients’ treatment adherence and satisfaction.

Regarding the program categories, the ratings for satisfaction in this study were higher than those reported by a study from Spain (3.83 vs 3.5 for basic intervention items and 3.42 vs 3.1 for specific intervention) [23]. People in Myanmar are known for their friendliness, easy-going lifestyle and a high tolerance for life’s inconveniences. This might be a factor for the high satisfaction scores observed in this study.

Many factors influence MMT treatment satisfaction. These include recent heroin injections, use of benzodiazepines, HCV infection, high addiction severity index (ASI), alcohol consumption and family/ social status. Limitations or barriers in methadone treatment such as dosing spaces, waiting areas and staff shortage [2], methadone dispensing hour, methadone dose change, the number of patients per centre, frequency of information about methadone dose changes, and lower social dysfunction subscale of General Health Questionnaire-28 [23]; could also affect treatment satisfaction.

Our stepwise binary logistic regression result showed alcohol consumption and physical health were significantly associated with methadone treatment satisfaction. Although Myanmar is a majority Buddhist country, alcohol consumption is common among its people.

There were a few limitations in this study. First, respondents for this study were randomly recruited from a few MMT clinics. Hence there could be bias by not enrolling clients unsatisfied with their MMT program. There is a limitation to make generalisations from the results bias the data were based on one-time self-reporting. The result’s further potential bias could be contributed by the selection criteria of a minimum 6-month treatment. The National indicator from the DDTRU (Drug Dependency Treatment and Research Unit) specified the client retention in the methadone treatment as “those clients who were taking methadone at least 6-month period”, and this survey excluded the satisfactory situation of the clients who were less than 6 months of the treatment. The 2018 annual data [16] showed 70% received at least 6 months, and we could interpret that the survey results were derived from the samples representing the majority of the clients. As the respondents were patients currently taking methadone, they might be reluctant to take risks in expressing negative views; Hawthorn’s effect thus could not be ruled out despite our efforts in ensuring confidentiality. We analysed this study with the Chi-squared test repeatedly to identify the satisfaction of the methadone clients. So, there could be a potential increase in type I error as there were multiple comparisons to test the null hypotheses [20]. Finally, factors like early drop-outs and refusal to participate in the study, could be a threat to the internal validity and generalizability of the results. In conclusion, our results indicated that clients in the MMT program in Myanmar were highly satisfied with their methadone treatment program. However, the lower percentage of satisfied clients for the specific intervention category compared with staff and basic drug management categories highlights the need for improvement in the Specific intervention component in MMT programs by providing ancillary services such as counselling, medical services (Individual rehabilitation), psycho-social services (psychotherapy, and group therapy), and psychiatric care.